Like most new doctors, Annette Schippel, DC, of Schippel Chiropractic in Jacksonville, Illinois, was idealistic when she graduated from chiropractic school, thinking an “adjustment cures everything.”
But she quickly found that while the adjustment is an amazing tool, her patients’ health wasn’t necessarily improving in all cases.
“I was getting frustrated and losing enthusiasm,” she says. “Where is the joy in doing this if you aren’t getting the results you want from your patients?”
So she dove in and began researching Functional Medicine (FM) and supplements, but she didn’t just offer up probiotics and omega 3s. She read into the science avidly, and what started with taking patients’ hair samples has today expanded to a broad spectrum of testing that she now uses to determine what supplements will be most beneficial for each patient.
“Nutraceuticals” can quickly become nothing more than a natural form of pharmaceutical therapy if providers aren’t careful, she says. But asking the right questions and using good diagnostic tools can help you focus and provide the best individualized treatments.
“Chiropractors have always been looked upon as being ‘alternative providers,’ ” she says. “If we open up our minds and take on that role, we are in a good position for a paradigm shift of actually getting patients well and not just abating their symptoms.”
Before initiating a battery of tests on patients, you have to know what it is you are looking for. Paul Goldberg, DC, MPH, who is a professor of clinical nutrition at Life Chiropractic College and the director of the Goldberg Clinic for Chronic Disease Reversal in Kennesaw, Georgia, says there are three components to understanding a person’s nutritional needs.
First, what level of nutrients should a person take in to have optimal health? Second, what should he or she be avoiding to improve their health? And third, what is interfering with a patient’s ability to use those nutrients and eliminate toxins?
When determining a health plan, practitioners should look at factors such as genetics, lifestyle, and environment, and diagnostics can play a large role in creating that plan. One basic diagnostic tool to start with is a physical examination.
During this exam, chiropractors can take vital signs, determine body fat composition, and examine specific areas where a patient has complaints. Goldberg says to pay close attention to a patient’s mouth, abdomen, skin, and nails—as these can all signal problems.
He notes that there is an order of operations one should follow: “Laboratory testing, for any purpose, to be used appropriately must be preceded by a thorough case history and physical examination.”
For instance, during an exam, Stephanie Zgraggen, DC, CCN, of Lime and Lotus LLC, in Charleston, South Carolina, saw that one of her patients had deep fissures in her tongue. This, she says, is indicative of vitamin B deficiency. She followed up with questions about her patient’s diet to see if she could increase intake or if she might need supplements.
Zgraggen says a fingernail analysis can indicate a patient might have a cardiovascular or thyroid issue, or a zinc or magnesium deficiency. If a person’s blood pressure drops when moving from a lying to a standing position, it can signal postural hypotension and a potential adrenal gland deficiency.
“These are things you can do in the office that are free and easy,” she says. “The body gives us many outward signals of nutrition deficiency.”
A diagnostic tool that is slightly more detailed than a physical exam, but which Goldberg says is the most important, is a case history (also known as a health questionnaire or systems survey).
This kind of questionnaire should take a comprehensive look at everything impacting a person’s health, including medical history, lifestyle, sleep, home environment, adrenal system, digestion, and cardiovascular and renal condition.
The can be a standalone tool or used in conjunction with other lab testing to determine what supplements are needed. For example: Chronic muscle spasms can be managed with magnesium supplements or further testing may be required to rule out conditions such as fibromyalgia.
Zgraggen said these approaches are great for determining what systems of the body might be the underlying cause of a patient’s symptoms.
And questionnaires of the type mentioned here can be purchased from organizations such as the Institute for Functional Medicine or from supplement makers.
The third step to understanding a patient’s needs is blood work. And there’s a bit of controversy in this space as to what is and isn’t needed.
It’s becoming increasingly popular for practitioners to order newer kinds of blood panels—those that test broad- spectrum vitamin and mineral levels— to determine whether the patient is presenting with any deficiencies.
On the other hand, many providers feel standard testing that includes blood cell count with differential, blood chemistry, HgA1C, lipid profiles, and thyroid panels, should tell providers most of what is they need to know.
Mark Kaye, senior manager of medical information at Metagenics, says vitamin tests can be expensive, are rarely reimbursed by insurance, and can be time consuming to perform.
They may, however, be helpful for resolving problems for patients who have been seeing a variety of practitioners without success.
Vitamin tests that can be helpful to a broader range of patients include an antioxidant panel, and testing for omega 3s and vitamins B and D.
When analyzing blood work, remember to look for a patient’s functional levels. Most labs use a specific set of numbers to determine whether or not patients may have a condition. But in the world of Functional Medicine, Zgraggen says you are looking for disease processes and trying to determine where a patient’s levels need to be to feel his or her best.
For Zgraggen, who specializes in female hormone health, standard blood work doesn’t give her the specifics she needs to treat her patients. Because hormones fluctuate during the course of a woman’s cycle, she performs saliva testing to see “the dance of hormones” that occurs over a month’s time.
“I get eight different hormones at 11 times, so I can see graphs and charts and the relationships to pinpoint where there are challenges in the cycle,” she says.
Other tests Zgraggen uses are hair analyses and gut panels. Hair samples provide information on nutrient levels and the presence of heavy metals in the system. Toxic elements are highly concentrated in the hair and can sometimes reveal exposure to them before symptoms appear or show up in blood work. Gut panels—saliva and stool tests—can provide a range of information, including the existence of food sensitivities, yeast, fungus, and parasites.
These tests can be performed at home and return results in two to three weeks.
A relatively new alternative test Schippel uses is live blood-cell analysis. She performs this in her office using a microscope to look at blood cells to determine if there is inflammation, cholesterol, fungus, oxidative stress, or vitamin deficiencies.
Kimberly Besuden, DC, owner of Besuden Chiropractic in Winter Park, Florida, has patients perform a seven- day food log, which does two things: First, it makes them aware of what they are eating. Second, it gives her an idea of where to suggest nutritional changes.
Now that you have a guide for evaluating patients, what do you do with the results you receive? Schippel says all too often she sees colleagues perform thousands of dollars’ worth of testing with no idea how to use it.
New chiropractors may want to intern with a DC who is experienced in Functional Medicine and diagnostic testing, or join a practice that is proficient in this kind of work.
For chiropractors already in practice, an appealing option is to take online courses, such as those provided at Functional Medicine University.
These are aimed at helping providers who want to understand diagnostic results and use nutrition and supplements based on the results. Continuind education or diplomate courses are also available on this topic.
The systems surveys that Besuden uses have software that allows her to choose supplements based on the results to support her patients’ systems. It has a program that tells patients how much supplements to take and when to take them, making it easy to keep to a schedule.
Some lab companies also offer tools to gauge their results and guide patients and providers toward proper supplementation. Metagenics, for example, has a medical information group that helps practitioners understand how to apply diagnostic findings. Most Functional Medicine labs also have technical staff who can offer suggestions on what lab tests to use based on a patient’s physical exam and health analysis.
Goldberg does recommend significant caution when taking advice given by a manufacturer or lab. “Any time you use a supplier’s products, there is clearly a strong underlying agenda to use their diagnostic tools, he says.
Schippel notes that your colleagues can be a good resource, too. There are chiropractors, she says, who perform a broad spectrum of testing and are willing to mentor others wanting to do the same.
“It’s easy to become isolated and chiropractors tend to be solo practi- tioners,” she says. “As a profession, collaborating more will make us stand apart in a really good way.”
Words of wisdom
Schippel works with patients all over the country, so she knows she needs to use labs and diagnostics that can be replicated anywhere. She is familiar with both local and online labs, where patients can order tests and share the results directly with the provider.
Online labs, co-ops, and cash payments are all options for keeping down the costs for labs and other tests.
Testing and diagnostics should be performed outside of a traditional chiropractic visit, Besuden says. She gives patients the survey and other tools in advance so they can fill it out at home prior to a Functional Medicine visit.
“Appointments are too busy to do all of this,” she says. Goldberg believes laboratory testing, when implemented, should be considered part of a patient’s education.
When test results are received, they should be shared with and explained fully to the patient to allow them to take an active role in their healthcare. “Too often, I hear from patients that they went through a series of tests at another doctor’s office. but don’t know what the results meant since no one explained them to them,” he says.
Finally, Zgraggen recommends that novices not bite off more than they can chew. Pick a topic you are interested in—hormones, the digestive system, or chronic fatigue—learn as much as you can about it, and focus there. This will allow you to explore your passion in greater depth.
“Even with training, it’s tough to be an expert on every area of the body,” she says.
Tammy Worth, a freelance writer based in Kansas City, Missouri, specializes in business and healthcare subjects. She can be contacted at firstname.lastname@example.org.